On the Edge

Doctors are prescribing too many opioid painkillers to young veterans, leading to addictions and accidental overdoses.

By the time Justin Minyard discovered the video of himself stoned, drooling and unable to help his daughter unwrap her Christmas presents, he was taking enough OxyContin, oxycodone and Valium every day to deaden the pain of several terminally ill cancer patients.

“Heroin addicts call it the nod,” the former Special Forces soldier says of his demeanor in that video. “My head went back. My eyes rolled back in my head.

I started drooling on myself. My daughter was asking why I wasn’t helping her, why I wasn’t listening to her.”

Seeing that video jolted Minyard out of a two-year opiate stupor. He asked a Fort Bragg pain specialist to help him get off the painkillers his primary care physician had prescribed. “I was extremely disappointed in myself,” he says. “I knew I couldn’t do that to my family again.”

There are thousands of post-9/11 veterans like Minyard – men and women whose bodies were broken by roadside bombs, bullets or jumping out of helicopters and Humvees day after day, deployment after deployment, wearing 80 pounds of body armor and battle gear. Some have traumatic brain injuries. Some have PTSD. Some have deteriorating knees, shoulders or spines. All have pain.

Overwhelmed primary care physicians have responded with ever-increasing doses of prescription opioids. There has been a 270-percent increase in VA prescriptions for four key opiates since 9/11, according to an analysis by the Center for Investigative Reporting. VA patients are twice as likely to die from accidental drug overdoses as civilians, according to a VA study published in the journal Medical Care in 2011. Yet opioid painkillers provide “only modest medical benefits in treating chronic non-cancer pain,” a separate VA study found.

In Minyard’s case, as in so many others, “the treatment regimen was as bad as the disease,” says Dr. Tony Dragovich, an Army pain specialist now in private practice in Virginia who helped get Minyard off opioids.

MULTIPLE INJURIES A series of debilitating injuries led to Minyard’s massive painkiller habit. The first occurred when he and other members of the 3rd Infantry Regiment spent six weeks moving piles of rubble at the Pentagon following the 9/11 attacks. He then volunteered for language school, and by the time he deployed to Afghanistan in 2004 as an interrogator he was already taking aspirin, ibuprofen, Vicodin and muscle relaxants, and was being administered epidurals for his back pain. “I was only 25,” he says. “And if you looked at an MRI, I had the spine of a 60-year-old.”

The injuries mounted. Minyard fell two stories during a combat operation in Afghanistan, on top of the wear and tear that comes from riding in a helicopter – the vibration in a Black Hawk is particularly hard on the spine, Dragovich says – and running around in full combat gear. He had surgery to replace two discs after he returned from that deployment. By then he was alternating between Percocet and Vicodin and should have stayed home. But because the Army was short of soldiers fluent in Arabic, he volunteered to go to Iraq in 2007.

“Looking back, that was probably one of the worst decisions I made,” Minyard says. “It had a lot of ripple effects beyond my health. I left when my daughter was three weeks old.”

His pre-deployment physical was a quick conversation with a physician sitting behind a desk, who asked if he “needed any meds.” Minyard doesn’t blame the doctor. “Probably half of the people coming to his office every day are trying to get out of deployment,” he says. “And he has to deal with 500 guys who are in line behind me.

He probably doesn’t care about Justin and his back problems.”

The op tempo in Iraq was as furious as the strain on Minyard’s body. Before his unit rolled out on missions, he gave himself injections of a super-strength anti-inflammatory called Toradol. Between them, he visited the medical tent for epidurals and additional pain medications. “That was a double-edged sword,” he says. It eased his pain while enabling him to continue harming his back.

Minyard’s pain was severe enough, however, that he went to the doctor while home on R&R. Fort Bragg physicians told him the damage to his spine was so significant that he shouldn’t return to Iraq. For him, that would have meant abandoning his platoon. “I chose my military family over my real family,” he says. “I chose the military over my personal health.”

The accumulated damage caught up to him. Minyard collapsed as he climbed out of a Humvee in August 2008. He was airlifted to Balad, where he sustained a concussion and additional back injuries after a nurse dumped him on the floor during a mortar attack, he says. Once home, surgeons at Duke University installed eight titanium rods to hold his spine in place – a procedure called an “anterior-posterior interbody fusion.”

Before doctors could operate, however, Duke had to bring in an outside team to figure out how to treat Minyard’s post-surgical pain given his high tolerance to opioids. They settled on ketamine in combination with other drugs that allowed Minyard to disengage from reality, he says. It worked. But by that time he was confined to a wheelchair and weighed 280 pounds.

For the next two years, Minyard struggled with PTSD, depression, severe cognitive challenges, the loss of his military career and anger over his injuries. He took ever larger doses of “big league opioids,” as he puts it. “No one said, ‘This is a problem.’ This was offered to me.”

Somewhere in that haze, he says he came close to killing himself.

“To go from a very successful career as a soldier to hiding out in our guest bedroom with the shades closed for weeks at a time, taking pain pills and being ashamed ... I considered taking the whole 30-day supply in one shot,” he says. “It would have been incredibly selfish on my part.” Though not unusual. Seven of his friends died in combat. Fifteen have killed themselves since coming back.

Minyard attempted to kick opioids three different times. “It was the most unpleasant, horrible, excruciating time of my life,” he says. In the middle of moving to a different home, he came across an unlabeled video, popped it in the VCR, and watched in horror as his near-comatose self couldn’t even help his daughter unwrap her Christmas presents. He asked his primary care physician at Fort Bragg to refer him to a pain specialist.

ACCIDENTAL DEATH An untold number of other veterans don’t get the sort of help that saved Minyard. A 43-year-old retired Army veteran died four days after back surgery in the fall of 2011. The Arkansas State Crime Lab ruled the cause of death as “mixed drug intoxication” complicated by back surgery. His widow, Kimberly Stowe Green, told the House Veterans’ Affairs Committee, “My husband – Ricky Green – died as a result of VA’s skyrocketing use of prescription painkillers.” Ricky’s medication list included oxycodone, hydrocodone, Valium, Ambien, Zoloft, Gabapentin and Tramadol. This despite her husband’s repeated requests that VA doctors treat the root cause of his medical problems – knee, back and ankle injuries acquired over his 23-year career as a paratrooper and military policeman – and reduce his prescription opiate painkillers, she said.

VA declined to answer questions regarding Green’s case, noting that it does not comment on specific patients. Overall, the agency says it has “worked aggressively to promote the safe and effective use of opioid therapy.” VA clinicians discuss benefits and side effects of medications with patients. Opting for opioids is “a collective decision between the veteran and their health-care team,” VA says. In addition, VA connects patients and families to “pain schools,” support groups and other resources.

VA has also adopted regulations aimed at reducing the risks of prescription painkiller use – a strategy it emphasized during that same congressional hearing. But VA hospitals and clinics are not adopting those changes, Green says. “They were repeatedly violated in my husband’s case – and he had to pay with his life.”

There are several other factors fueling the prescription painkiller epidemic, according to congressional testimony from The American Legion. Veterans can receive overlapping prescriptions from DoD, VA and TRICARE, and Medicaid or Medicare providers. Physicians often have difficulty distinguishing between TBI, PTSD and pain issues. The result is over-reliance on painkiller prescriptions. In addition, there is a significant need for prescription painkiller oversight among VA providers, the Legion says.

Meanwhile, Iraq and Afghanistan veterans who are at the greatest risk of addiction and accidental overdoses are the most likely to receive opioid painkillers from VA, according to a VA study published in 2012. This was particularly true if the veteran also had PTSD.

“People at the greatest risk of addiction and overdose are the people who are going to have the most distress from their pain,” Dragovich says. “If a patient comes to you with a lot of psychological distress and a lot of pain-related distress, most physicians are going to give them opioids.”

STANDARD PROCEDURE High doses of opioids became standard protocol for pain treatment in the late 1990s and early 2000s, Dragovich says. When that protocol is applied to a military base with 1 million primary care visits a year, the result is a lot of opioid prescriptions. Because young soldiers build tolerance to opioids quickly, he adds, doctors escalate the doses quickly.

Severely injured servicemembers also often come out of the hospital receiving high doses of opioids for traumatic battle injuries such as the loss of an arm or leg. Then they are faced with the excruciating work of getting off opioids for good. That’s not an easy sell no matter the patient.

It took Minyard six months from his first meeting with Dragovich to agree to try the doctor’s plan for helping him kick opioids. Dragovich used a drug called Suboxone to ease Minyard’s transition off the painkillers. He also arranged for him to get a spinal-cord stimulator that uses electrical impulses to short-circuit pain messages before they reach the brain. He calls it a pacemaker for pain.

“(It) was like a lightning bolt,” Minyard says.

“I felt like this was going to be the one thing that helps turn me around.” It did. Today he’s out of his wheelchair, has lost 100 pounds and regularly bicycles.

The Army supports the use of spinal-cord stimulation, but there are few specialists to guide soldiers to such alternatives. Fort Bragg had two board-certified, fellowship-trained pain specialists while Dragovich was stationed there. As a result, it may take three or four years of other treatments before injured troops see someone with Dragovich’s expertise.

It’s also difficult to get a referral to a pain specialist in VA, says Minyard. And it’s quite difficult to receive spinal-cord stimulation at VA. “You have to fail at all other treatment plans,” he says. “Is failure an overdose? Or is failure when you are a full-blown addict?”

Minyard, who is 90-percent service-connected for his injuries through VA, has charted his own recovery. He took his last opioid painkiller in October 2011. At his Army retirement ceremony in March 2012, he thanked Dragovich for saving his life. He feels so passionately about staying off opioids that he has a medical directive prohibiting the use of narcotics without his consent. And if he’s unable to provide that consent, his wife has to agree to it. He tested that directive when he was struck by a truck while bicycling at Fort Bragg – an unsolved hit-and-run. But he has no second thoughts about opioids.

“I consider myself extremely lucky,” he says. “I was able to push through the maze of providers ... and find the doctor who knew the secret. Many soldiers aren’t so lucky, and are left to the crushing reality of lifelong opioid dependency. Or worse.”

Ken Olsen is a frequent contributor to The ​American Legion Magazine.

Scott Murphy, combat Veteran Iraq War

Any veterans that want to work on allowing all our battles to have the doctor approved choose to try medical cannabis, especially when other drugs have not worked, hit me up at murphy9682 at gmail. If you think all veterans that use cannabis are hippies and should die also please hit me up.

LexusAna

I carefully take a hydrocodone (1-2 tabs. a day )for severe arthritis. It HELPS me. I can then do chores like walking my dogs and yard/housework. I'm not a drinker or marijuana user. Have never used street drugs.

I fear that this type of (scare) article will stop the V.A. from allowing me to get this prescription. I must go now to a non-V.A. doctor and pharmacy to get Zetia (cholesterol med.) The V.A. doesn't carry it.

terrysrsr

Wow, a ton of information on here about how the VA is screwing up! I've had VA medical care for more than a few years now because of a long term back problem. I've been taking the low dose of 5mg Vicodin. I'm so sick and tired of the doctor and nurses threatening me every time I go in for a checkup about the dangers of using this drug.

I've been on Vicodin for almost 4 years now, if the drug was so frigg'n bad, why did they have me on it for all these years? They've never ONCE raised my medication, even though any half wit knows that anything you take long term, your body becomes ammune to it pretty much, and obviously you need to either take more, or raise the dosage.

I'd much rather go in, have my back operated on, and actually fixed instead of taking all this medication. But, the VA won't have that. It's cheaper, and easier for them just to keep going through all this garbage with me, stringing me along as long as they can. It's all a money game with them, that's it.

Now I go in to the VA every few weeks for blood work, urine tests, ultra sounds on my liver, ect. Anything just to make it look like they're doing something. Every time I go in there now, I ask, how is this going to fix my back? And, every time, I get the puzzled look from the doctor and nurses. The real answer is, this won't do a damn thing to fix my back. There's nothing else wrong with me, they just keep doing all the tests to make it look like they're doing something.

All I have to say is, what a fun and profitable little game they play over at the VA. It's a real pain for the guy that has to live with it.

Bob USMC 08

This article is good as far as it goes, but the situation is much deeper.
Check out the Citizens Commission for Human Rights site (CCHR) to read about The Hidden Enemy. for the even greater threat. I'm a Vietnam veteran, and hate to see what is happening to our boys and girls.

kmb42vt

I'm a veteran of the Cold War Naval Submarine Force. I'm rated at 90% but being paid at 100% due to unemployability. I have an injured spine (lower) and a gut full of surgery due to injuries/damage due to ulcers sustained in during my 12 years on subs. Increasing chronic pain levels and failing health finally took me out of the work force in 2007 after 30 years of working full time and better (couldn't make the 10% work any longer). I began taking a minimum dose of oxycodone (5 mg) in 2006 just so I could get enough sleep each night so I could work the next day. Since then the dosage has been increased to 10 mg a day (5 mg taken at supper and bedtime) which is just enough to "take the edge off" the chronic pain so I (and my wife as well) can get some sleep.

I'm the odd-ball out here it seems. I've actually stopped taking the oxycodone twice by my own choice, once for 6 months and once for 4 months without any withdraws, cravings or side effects, probably due to the very low dosage, with the exception that the chronic pain increased rather significantly, but that was to be expected. My VA PCP understands the kind of pain I'm in and has offered to increase the dosage since 10 mgs is almost nothing but I always refuse.

But what I wouldn't give if the VA actually offered a cannabis based pain medication that a vet could get right from the VA itself rather than being forced to being put on a state list and having pay for and then smoke the stuff.

Kenackr

I'm a 100% service connected disabled vet with severe lower back & upper right scapula pain that has been given opioids by the VA for pain relief. It became obvious to me that I was becoming an addict. I had a straight face to face with my primary care doc and asked directly for alternatives to manage the pain, not once, but 4 times over the last year. Absolutely no response has been forth coming. I only take them now when the pain is so great that I feel that suicide is the best way out.

I have now put in a complaint to the VA OIG about the fact that there has been no response from my doctor, that I'm being ignored. The very next day after I submitted the complaint I got a standard response email saying that the OIG is overwhelmed with complaints and cannot follow up on every one because they don't have the staff, and that it will take them 6 weeks or longer to determine if my complaint will be investigated.

The reality is, that I think the doctor's hands have been tied by the administrators who know that pills are comparatively cheap and that alternative treatments may cost more. Further, that if the administrators allow the doctors to spend what it takes to help patients, that the administrators BONUSES will be negatively impacted due to rising cost! I believe that is the real reason why nothing is being done for us.

If we collectively start demanding that this problem get investigated either by the VA OIG or a special counsel empowered by Congress, we might get somewhere. If we all started bombarding the network news organizations that might turn up the heat to get them to act on our behalf also. Maybe it takes both as a combined effort.

ONE THING IS FOR SURE, IT WON'T GET FIXED IF WE JUST TALK TO OURSELVES !!!!!!!

Start writing or emailing the : VA, OIG, Congressmen/Senators, Network news, etc. and tell them to investigate this shameful treatment to those of us who served and are now suffering with great pain. And don't stop. Get your friends, neighbors, relatives, church, etc all to do the same and it's OK to send the same letter or email more than once. United, we stand as brothers & sisters once more and if don't unite, we fall.

Justin Minyard

Cjohnson

Dara - My heart goes out to you and your husband. Try asking the doctor for a referral to an acupuncturist. It may be easier to get through the red tape and it has been proven to be a successful drug replacement at Walter Reed.
See the movie "Escape Fire" for more info! Good luck.

Widow in pain.

My husband was being treated by VA for his chronic, increasing, pain. He was 100% service related disabled with many health issues. He had a great amount of pain, suffering from MS and many broken bones from falling. He was housebound, in a wheelchair unable to stand or walk. His new SCI (Spinal Cord Injury) doctor who, saw my husband once, decided he should be cut back on Morphine because of a guideline issued by the VA. This caused my husband to suffer so much, it was cruel! He died 2 wks later in Feb. He shouldn't have suffered like he did before his death. You can't practice medicine by applying general rules. Each person/patient is different. The use of pain medications should be monitored, by a physician, and applied to individuals, not across the board because of over prescribing medications by others. It breaks my heart to have seen him suffer needlessly. Shame on the doctor.

54Gunner

Sister, (You are my Sister because your husband was my Brother In Arms) You are exactly right, and I am saddened and angered by your loss, and by the suffering your husband endured because of idiotic, impulse applications of "the new idea" in the treatment of pain. What works for one person does not automatically work for another person, but because the people making such decisions are NOT the Veterans suffering in pain, the issue is treated with a capricious indifference. I am appalled that The American Legion, which is supposed to be a Veterans' and Service Members' ADVOCACY and SUPPORT Organization, so readily jumps on the political bandwagon that has been put forth by the low-lifes who are interested in cutting troop strengths, cutting Veterans' Benefits, and in general, Treating Military and Veterans as an annoyance that costs money rather than what we Truly Are: The Backbone Of The United States Of America. God Bless You, and May Your Late Husband Rest In Peace in the knowledge that there ARE Veterans who are aware, and are speaking out against all of us being treated with One Diagnosis, and shoved out the door. This does not happen in every case, but dammnit, Why Does It Happen At All?

CB Bob

As a Vietnam Veteran benefiting from the use of cannibus I want to thank the VA for approving pot for medical use in the states it can be obtained
legally. I had to relocate away from my family to get the medacine I need, but I will be healthier, happier and live longer without sleeping pills or blood pressure meds.

Menyu12

Not everyone is the same. I suffered massive pain from my back & Neck for many years. They tried everything except pain medication. After going to a the pain Clinic--I was given a very low dose of Methadone
(I/2 tab twice a day) and It didn't take the pain away but it made it tolerable. I do have PTSD and I don't even drink alcohol so, it bothers me when people say PTSD and Addiction in the same sentence. I took this small dose for several years until 2013 when I called for a refill and without an explanation or plan, I was told 'No' and stop taking it 'Cold Turkey'. I was fine for about 2-3weeks ,at least until my back remind me of the pain. I don't think that I had any withdrawals and I don't know why. I think I was treated that way because of the stereotyping That people label PTSD and addiction. I would have preferred My Doctor to at least discussed this with me and shared a plan of care. I didn't get that Opportunity. It was just a simple 'no' during a telephone refill. I'm finding out now, it was about decreasing the number of "veterans' taking pain Meds. An Appointment and discussion would have been appreciated and if people stop stereotyping I wouldn't have been treated like a number. I have good and bad days; I suffer a lot with mostly Neck pain and I take massive amounts of Aleve, Tylenol, Motrin and whatever they sell over the counter. I've tried all of the non-medication stuff through years going to the pain-clinic. Please stop stereotyping we are not all the same....

TAJUANA

I work with this everyday and I feel that the Va is creating drug abusers who know that they can get the medication so easily and yes they let the doctor know of their pain but I feel it's up to the doctor to suggest other alternatives beside pain medication because we are crating nothing but pill heads. Pain medications aret the new street drug also they are either selling it or taking way too much!!!!
Something need to be done and ASAP!!!!!!

MrDap

I've been treated by the VA for 8 years for injuries sustained when I was wounded in combat in Iraq. After being treated at 2 different VA facilities and by 6 different doctors, I've yet to find one doctor that didn't go to extreme lengths to explain the dangers of opioid pain medication and vehemently advise against taking them if the pain could be managed in any other way. They also regularly administer blood work to test for liver and kidney function as well as urinalysis drug screenings to insure that the medication isn't being abused or mixed with other drugs, either illicit or prescribed.
However, somehow every time someone gets addicted to pains pills it's always the "doctor's fault", but in reality, the patient asked for the medication they received and fully knew what they were asking for.
The doctor doesn't tell patient how much pain they are experiencing. The doctor doesn't tell the patient that they need an increased dosage of medication. These are things that the patient tells the doctor and the doctors do what they can to ease the pain symptoms that they are told about. Are they supposed to say "No, deal with the pain"?
The bottom line is that these veterans are adults and they know the dangers of opioid pain medication and they know what dependance/addiction is. They tell the doctor where it hurts, and the doctor tries his or her best to help them and ease their pain.
Act like an adult and take some responsibility for your own actions. Research the medications you put into your body and stop trying to blame the people who have only been trying to help you.
The doctors, nurses and staff of the VA deserve our thanks, not our scorn.

jeb stuart

Kudos great article. But I would also suggest from my own experience Doctor's are too willing to prescribe pain killers for other maladies. When I had a service related back injury instead of suggesting chiropractic solutions or an operation they suggested pain killers in part to get me back into the fight and alleviate the guilt and sense of anxiety coming from failure of being down; they did not offer another solution.
This is not just a Military problem. Maybe part of the problem is the result of how immersed medical practitioners have become in prescription solutions from a bottle determined by pharmaceutical companies interested in volume and sales versus more constructive Doctor Patient interaction. When Docs are stuck feeding symptoms into a table without more knowledge of the patient pharmaceuticals seem to be the only solution and addiction can be calculated from the same sort statistical data bases used to prescribe the drugs in the first place.
What i wonder is did they bother to calculate how many persons suffering from PTSD treated with drugs would likely become addicts and was it determined an acceptable risk?

jaacson

Thank you for your piece "On the Edge," the effects of increased prescriptions of opiates have been well documented and are a serious issue. However, although there was a section on alternative treatment, there is no mention of medicinal marijuana as a safer, less habit forming alternative. The American Legion seems silent on the issue and many veterans fearful of the effects of opiates use medicinal marijuana in states that allow it. This despite the fact that the VA discourages the use and even study of marijuana's medicinal purposes and possibly positive effects on both the PTSD/TBI and pain fronts. Here in Arizona, the legislature has refused to hear a bill that will allow even a discussion over a University of Arizona proposal to study the effects medicinal marijuana on PTSD patients. It is my hope that the American Legion will lead the charge in getting veterans access to the best care, regardless of the social stance many veterans and veterans organizations take regarding marijuana for recreational use. Maybe it will take multiple deaths and addiction to show that medicinal marijuana should get another look, but it shouldn't.